E-Learning Center : Program Information : Programs : Terre Haute Boys & Girls Club

Child's Name

First Name *

Last Name *

Grade Fall 2020 (Required)

School Fall 2020 (Required)

Age (Required)

Gender (Required)

Parent/Guardian

First Name *

Last Name *

Parent/Guardian Mobile Phone (Required)

Parent/Guardian Work Phone (Required)

Parent/Guardian Email (Required)

Day/Week Registering For (Required)

Medical Condition (Required)

Please explain Medical Condition

1ontkikukzdl

Electronic Signature of Parent or Guardian (Required)

Date

Month

Day

Year

Email Address for Confirmation of Submission (Required)

Online Clubhouse Program Cost

$10.00 per day. Choose box that applies to number of days your are registering for.

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged